Automate Your EMR Cow Paths *and* Reengineer Them Too!

Short Link: http://j.mp/6wKM66

Last Wednesday I attended a conference on “The Economic Stimulus Package and Healthcare Technology: How Will the Stimulus Money Flow and How Can You Prepare?” at Georgia State University. (Details at the end of this post.) There were over 300 attendees. Many of the people that I met were new to healthcare, but drawn to it by news of the pending federal stimulus monies for HIT. I agreed with and greatly appreciated *almost* everything that I heard.

My only quibble was the shared sentiment (expressed at the conference and frequently elsewhere) that getting physicians to change their workflow is one of the biggest barriers to EHR adoption.

cows-150x150

Michael Hammer’s 1990 “Reengineering Work: Don’t Automate, Obliterate” Harvard Business Review article popularized the analogy that automating existing processes is akin to paving a meandering cow path instead of what should be done, which is to create a road that proceeds straight from point A to point B.  When successful, the results can be substantial increases in effectiveness and efficiency. However, business process reengineering failure rates have been reported to be 50 to 70 percent (or higher, given natural human reluctance to admit or publicize failure). User resistance is often blamed. Similar levels of failure have been reported for EMRs (this 2006 study is representative). The basic problem is that implementing *most* EHRs is an act of reengineering, and reengineering is a high risk endeavor.

A good way to explain this success rate is through use of the classic Thesis-Antithesis-Synthesis method of using a contradiction to motivate conceptual innovation:

  1. Thesis: “Instead of embedding outdated processes in silicon and software, we should obliterate them and start over.” (Hammer, 1990)
  2. Antithesis: There are many, many reasons people resist change, and not all of them are bad.
  3. Synthesis: Automate the cow paths (so as to minimize the psychological shock of automating previously manual processes) and then systematically but gradually straighten and widen these paths until a straight and wide digital superhighway is attained.

How is it possible to “systematically but gradually” improve automated workflows? First implement workflow management system process definitions that fit the way workflow is already being accomplished. Second let users get used to the new technology. And third, only then gradually change the process definitions that determine EHR behavior at a rate that is no faster than can be tolerated. The workflow management system foundation, with its workflow engine that executes easily changed process definitions provides the means to accomplish process changes that do not require rewriting and recompiling software code. The business process management layer provides the means to systematically optimize process effectiveness, efficiency, and flexibility. (More on EMR BPM in this previous post.)

To summarize my main point:

Using EHRs that are easily molded to existing physician workflows, which can then be systematically improved while respecting normal human tolerance for change, is the key to EHR adoption.

Here is a bit more info about the excellent conference that provoked this post:

“The Economic Stimulus Package and Healthcare Technology:
How Will the Stimulus Money Flow and How Can You Prepare?”

Technology Association of Georgia,
Georgia Health Information Exchange, and
Georgia Chapter of the
Health Information and Management Systems Society

May 14, 2009,
Georgia State University
Atlanta, Georgia

Could You Do Me a Favor? “Electronic Medical Record Workflow Management: The Workflow of Workflow”

Short Link: http://j.mp/7jekkh

Could you do me a favor?

SERP stands for Search Engine Result Page. A white paper I wrote in 2003 about EMRs and workflow has consistently had a Google SERP rank = 1 for the search terms “EMR” and “workflow” (out of 177,000 total hits, when I most recently checked, see below).

google_emr_workflow_pagerank_no_jmjtech1

Over the past decade I occasionally queried Google using the search terms “EMR” and “workflow” (and then also “EHR” and “workflow,” as “EHR” became increasingly popular, though “EMR” continues to outnumber “EHR” two or three to one). At first I was just interested in what was out there and wanted to make sure I read all the relevant material I could access. Periodically I’d repeat the search to make sure I caught any new material that appeared since last I searched.

[9/24/12 Update: The next link doesn’t work because the JMJtech.com domain is gone. However, the link to a copy of the paper on my blog still works. However, not matter what you search for in Google, that working link is gone, gone, gone….]

After a while I started to find my own material. The 2003 white paper I wrote called “Electronic Medical Record Workflow Management: The Workflow of Workflow”drifted towards the top of the Google search engine results and eventually occupied the first position on the first page of links that Google presents in response to the query of “EMR” and “workflow”. (However, please note the P.S. below dated 6/11/2009, below!)

If you have read this far, you may be thinking: “What’s the favor?” and perhaps even “This guy is a bit obsessive!” In my own defense, I think that “EMR” and “workflow” are important search terms. First, I find much of the material on the Web that includes these terms to be potentially interesting. Second, if someone uses these terms and informs themselves about the subject, I think this is a good thing (the value of an informed public and all that). Third, if someone reads the “Workflow of Workflow” white paper, they may become interested in the EMR (now EHR) workflow management system that illustrates the ideas explained in the white paper.

Since a document’s SERP rank in Google is in large part determined by who links to it and resulting traffic, I guess I have only one thing left to say:

Could you do me a favor?

Please click on the following link: http://www.google.com/search?hl=en&q=EMR+workflow and then click on the link to the “Electronic Medical Record Workflow Management: The Workflow of Workflow” white paper (a PDF document) returned by Google’s Search Engine Result Page. (Better yet, also add a link to it from your web site please!)

Thank you!

P.S. (6/11/2009) Not willing to leave well enough alone, as an experiment I used a 301 permanent redirect to move the white paper from its old location to

www.chuckwebster.com/papers/workflow_of_workflow_white_paper.pdf

and its search position dropped like a rock. Oh well! It was fun at the top of the Google search engine result position heap while it lasted. (Maybe it will crawl back up, or maybe it won’t. It will be interesting to observe.)

P.S. (6/21/2009) Cool! It worked. Never mind.

Video Interview Dr. Armand Gonzalzles: BPM and EMR Workflow Management in Primary Care

Short Link: http://j.mp/5zhtCX

We caught up with Dr. Armand Gonzalzles, a Chicago-based pediatrician, after his recent presentation at HIMSS to conduct a short (eight minute) video interview, in order to explore some of the excellent questions from his audience.

Dr. Gonzalzles starts off with some general observations about EMRs, workflow management, and business process management, and the need for healthcare to catch up with other industries that are more advanced in their adoption of these technologies. He then addresses the following questions:

  • How did your patients react to use of an EMR?
  • Is it easy or hard to change your office workflows?
  • How long have you been using the an EHR workflow system and have you ever been tempted to change?
  • Is it difficult to keep the system up to date with respect to codes and drugs?
  • Have you integrated patient education into your workflow? Does it save you any time?
  • Could you share some general impressions about the impact of a BPM-style EMR workflow management system on your return on investment, patient satisfaction, and personal workload?

[flv:http://www.chuckwebster.com/video/interview_EMR_WFMS_BPM/interview_dr_G_040809.flv 320 240]
I am especially intrigued by Dr. Gonzalzles’ use of the phrase “business process management,” because BPM has so much to offer to the optimization of clinical outcomes, patient satisfaction, and practice profitability (particularly as EMR workflow management systems evolve into full-fledged EMR business process management systems).

P.S. (Update) I believe I was the first to present and write about an in-production EHR workflow management system, what might be called an EHR BPM system today, at the 2000 HIMSS conference in Dallas. I gave a similar presentation at the 1999 MS-HUG conference, though there was no published paper. There is, however, a blog post about the 2000 presentation, with links to the proceedings paper. From that blog post:

“In three ways, [the 2000 HIMSS presentation and paper] prefigured developments that are beginning to affect collective thinking of the HIT industry today:

  • Workflow management systems (business process management today)
  • Computer-supported collaborative work (groupware and workflow systems today)
  • Componentized EMR architecture (software modules/plugins and service-oriented architecture today)”

“Meaningful Use” and EHR Business Process Management

Short Link: http://j.mp/5wN38z

I attended the National Committee on Vital and Health Statistics hearing on “Meaningful Use” on Tuesday and Wednesday of this week. The NCVHS advises HHS on EHRs, among other things. The recent ARRA bill included billions for HIT but stipulated that only “meaningful use” of EHRs should qualify for financial incentives. However, the bill kicked the can of what meaningful use meant down the road. This hearing was about picking up the can and doing something useful with it. There were a lot of workflow and workflow-related ideas discussed.

I most liked this definition of meaningful use (from John Halamka, MD, a Boston CIO): Meaningful use is (or should be) “Processes and workflow that facilitate improved quality and increased efficiency.”

What struck me is that “processes and workflow that facilitate improved quality and increased efficiency” is essentially business process management applied to healthcare. The “business process management” industry is what the “workflow management systems” industry evolved into. EHR users need more than automated workflow; they need ability to systematically optimize the effectiveness, efficiency and flexibility of that workflow.

Optimizing clinical outcomes, optimizing patient satisfaction and optimizing practice productivity—are all forms of business process management applied to medical practice. An EHR “workflow management system” automates workflow; An EHR “business process management system” optimizes that workflow along dimensions that matter most to office-based physicians in private practice: clinical outcomes, patient satisfaction, and practice profitability.

You can think of this triad of clinical outcomes, patient satisfaction, and practice profitability as conceptually similar to what is called an objective function in operations research (of which I took a few courses as part of my Industrial Engineering degree). An objective function is the combination of things that need to be maximized, although sometimes at expense of each other (the trick is to find the workflow changes that are win-win-win in the sense that these tradeoffs are ameliorated or eliminated). You can think of automated workflow as a decision variable that is manipulated in order to find better workflow that will maximize the objective function value within a given environment (the set of constraints bounding the practically possible set of workflows).

Non-workflow-management-system-based EHRs are difficult to optimize in a business process management sense. Their workflows (decision variables) are highly constrained by the initial design decisions of the programmer. Their lack of easily changed workflow or process definitions makes it more difficult to systematically improve workflow in order to systematically improve clinical outcomes, patient satisfaction, and practice profitability.

To make this a bit clearer I’ve adapted a diagram from Process Aware Information Systems: Bridging People and Software Through Process Technology (Wiley-Interscience, 2005)

processawareehrlifecycle

EHR business process management adds EHR management and modeling tools to the EHR workflow management system portion of this diagram.

From page 11 of Process Aware Information Systems: Bridging People and Software Through Process Technology:

In the design phase, processes are designed (or redesigned) based on a requirements analysis, leading to process models. In the implementation phase, process models are refined into operational processes supported by a software system. This is typically achieved by configuring a generic infrastructure for process-aware information systems (e.g., a WFMS, a tracking system, a case handling system, or an EAI platform). After the process implementation phase (which encompasses testing and deployment), the process enactment phase starts—the operational processes are executed using the configured system. In the diagnosis phase, the operational processes are analyzed to identify problems and to find aspects that can be improved.

In order for EHRs to become business process management systems, capable of systematically optimizing clinical outcomes, patient satisfaction, and practice productivity, they must first become “process-aware.” The most logical process-aware information system foundation on which to implement an EHR is a workflow management system. EHRs capable of true meaningful use, that is, capable of “processes and workflow that facilitate improved quality and increased efficiency,” will need to incorporate both workflow management system and business process management technology into their designs.

(EHR) Workflow Management: Models, Methods, and Systems

Short Link: http://j.mp/6lbvOW

One of the most important researchers and writers about workflow management systems and business process management is Wil van der Aalst of the Eindhoven University of Technology. In 2002 Prof. van der Aalst and Kees van Hee published a book through MIT Press titled Workflow Management: Models, Methods, and Systems (WM:MMS) that has been remarkably influential.

workflow_management_models_methods_systems

(And no, I do not collect a commission if you click through and purchase this excellent book from Amazon!)

In WM:MMS, van der Aalst and van Hee present a history of software application architecture that places workflow management systems in historical context and argues that software applications will increasingly become workflow management systems or incorporate workflow management system features. While WM:MMS does not specifically address EHRs, I see no reason why EHRs would be exceptions to this predicted evolution. WM:MMS goes on to describe a notation for modeling workflow processes (called Petri nets), workflow management system functions and architecture, case studies, workflow management system development methodology, and a glossary of workflow management definitions.

Interestingly, Prof. van der Aalst gave one of the main keynotes at the 2004 MedInfo conference in San Francisco where he said that while he had looked through the two thick volumes of 300 hundred or so medical informatics papers and saw the word “workflow” a lot, it did not seem to be used in the way in which it is usually understood within workflow management systems research and industry. (By the way, I did catch up with Prof. van der Aalst afterward to confirm that my paper and poster did indeed discuss workflow in the workflow management systems sense.) This is consistent with my own experience. After a presentation on EHR workflow management systems, someone from the business process management industry will sometimes come up and say the same thing as Prof. van der Aalst. They’ve attended presentations about workflow but very few used the word “workflow” in a manner consistent with the way in which the word is used in the WfMS/BPM industry.

However, workflow management systems (and now business process management) ideas, terminology, and technology are finally beginning to gain traction in the health information technology industry. A great deal of credit for this progress is due to Soarian from Siemens, which is based on the TIBCO Staffware workflow management/business process management platform. Soarian’s use has won a major award from the Workflow Management Coalition.

Workflow management systems have also been used for a variety of “paper shuffling” purposes by hospital administrators and healthcare payers, but not so much in ambulatory medicine. This is too bad, since workflow engines uses workflow, or process, definitions to drive task execution and minimize what industrial engineers (I am one, or at least have a degree in IE) call cycle time and to maximize throughput. Workflows can be changed as circumstances require by editing these definitions (instead of requiring a programmer to rewrite and recompile computer code, and all the other associated tasks of testing, redeploying, retraining, and so forth). EHRs based on workflow management systems platforms would have much more usable workflow than many current EHRs without workflow engines and process definitions.

Twitter Updates About Dr. Gonzalzles’ Workflow Management EMR Presentation

Short Link: http://j.mp/8QUWct

Last week I attended a presentation by Dr. Armand Gonzalzles on “Workflow Management EMR Systems and the Primary Care Physician” at the HIMSS conference in Chicago.

workflow_management_emr_systems_slide

As an experiment and a means to share my experience I invited members of the EncounterPRO community to follow my twitter updates during that presentation. These “tweets” turned out to be a pretty concise outline of Dr. Gonzalzles’s salient points so I am posting them here.

introduction_dr_gonzalzles_himss

Especially interesting were the questions (starting about 11:11 AM) both in terms of quantity (I could only text fast enough to catch every other question) and quality (especially in the way they drilled down into the whole “workflow management” concept).

I include tweets here from the presentation that followed because that speaker specifically commented (12:17AM and 12:28AM) on both the relevance of Dr. Gonzalzles’ presentation and that the EHR he uses apparently has much more customizable workflow than is typical for most EHRs on the market.

(For those familiar with Twitter, I have reversed the order of the updates so that non-Twitter users can read in order from top to bottom. For those unfamiliar with Twitter, the following texts were entered by thumb and therefore the typos come with the territory!)

default_profile_normal chuckwebster Hi, am trying on Twitter for size and thought you might be interested. Am in Chicago at the Health Information Management Systems Society
10:59 PM Apr 4th from web
default_profile_normal chuckwebster Currently at Dr G’s talk, to begin 15 minutes
10:16 AM Apr 5th from txt
default_profile_normal chuckwebster About 120 attendees, not bad for sunday morning!
10:50 AM Apr 5th from txt
default_profile_normal chuckwebster Up to 200!
10:52 AM Apr 5th from txt
default_profile_normal chuckwebster Excellent presentation so far! (Mentioned my 2003 white paper EMR Workflow ManagementF The Workflow of Workflow)
10:56 AM Apr 5th from txt
default_profile_normal chuckwebster Slide: Workflow Definitions: The Heart of WFMS (screen capture of EncounterPRO’s workflow editor)
11:00 AM Apr 5th from txt
default_profile_normal chuckwebster …Customizable and anticipatory…
11:01 AM Apr 5th from txt
default_profile_normal chuckwebster …customization per specialty (primary care or specialist)…
11:03 AM Apr 5th from txt
default_profile_normal chuckwebster …favorite consultants referrals default workfow with correct phone number email etc…
11:05 AM Apr 5th from txt
default_profile_normal chuckwebster Assign work lists dependent on resource and role (nurse vs admin)…
11:06 AM Apr 5th from txt
default_profile_normal chuckwebster Resources: front desk, nurse, physican…
11:07 AM Apr 5th from txt
default_profile_normal chuckwebster 2 person vs 3 person office workflow …
11:08 AM Apr 5th from txt
default_profile_normal chuckwebster On the last side and in summary I was quoted!!!! “In the words of Chuck Webster, MD…”
11:08 AM Apr 5th from txt
default_profile_normal chuckwebster 11:08 AM Apr 5th from txt
11:08 AM Apr 5th from txt
default_profile_normal chuckwebster Question: How did patients react? Pleased! Excited! Legible prescriptions. E sign in. Decision support. Digital pictures of child in system
11:11 AM Apr 5th from txt
default_profile_normal chuckwebster How did you educated yourself about workflow? Cut out steps, combine steps, adjust workflow, combination reading and practical experience
11:12 AM Apr 5th from txt
default_profile_normal chuckwebster How interact with external paper oriented organizations? Scan in. Will be awkward until others catch up?
11:13 AM Apr 5th from txt
default_profile_normal chuckwebster Downtime? Twice in 10 years due to power outage. Used paper and reentered. One disaster: had backup so just inconvenient.
11:15 AM Apr 5th from txt
default_profile_normal chuckwebster Is it easy th change workflow (from student)? Yes. Value of workflow management system screens are anticipatory, easy to learn new sequence
11:16 AM Apr 5th from txt
default_profile_normal chuckwebster How change workflow? (Stubborn providers, resistance to change) Must prepare staff for change, show them the system, train them to comfort)
11:18 AM Apr 5th from txt
default_profile_normal chuckwebster Continued answer: learning curve is much shorter because sequence of screens fit each users role. Simple and fun to use
11:19 AM Apr 5th from txt
default_profile_normal chuckwebster What system do you use for 10 years? EncounterPRO from EncounterPRO Healthcare Resources (used to be JMJ)
11:20 AM Apr 5th from txt
default_profile_normal chuckwebster Are you tempted to change EHRs? No, EncounterPRO is still the easiest to use and mantain that I have seen
11:21 AM Apr 5th from txt
default_profile_normal chuckwebster Lots of questions!
11:22 AM Apr 5th from txt
default_profile_normal chuckwebster Dr G’s vision local ehr talking to local systems talking to state systems (no just concept, but hopefully in the near future it will happen)
11:25 AM Apr 5th from txt
default_profile_normal chuckwebster Smaller vendors or big vendors to get customizable workflow?: smaller
11:25 AM Apr 5th from txt
default_profile_normal chuckwebster Are you customizing workflow or code? Workflow, set up to shorten workflow for simpler problems.
11:27 AM Apr 5th from txt
default_profile_normal chuckwebster Did you have to draw your workflow? No EncounterPRO was already very close to my workflow.
11:28 AM Apr 5th from txt
default_profile_normal chuckwebster With emr workflow managment everythings flows smoothly (not like a hunt and peck word processor like most EHRs)
11:29 AM Apr 5th from txt
default_profile_normal chuckwebster Multiple workflows for multiple patients? Easy, workflow are based on diagnosis or treatment a different workflow is triggered
11:32 AM Apr 5th from txt
default_profile_normal chuckwebster How long to implement system? Are new codes or drugs problematic? Week! New stuff easy to add (or delete)
11:33 AM Apr 5th from txt
default_profile_normal chuckwebster Are you reimbursed for emails? Yes, not as much, but much less time
11:34 AM Apr 5th from txt
default_profile_normal chuckwebster Can pat ed materials be included in workflow? Does it save you time (less teaching)? Yes.
11:35 AM Apr 5th from txt
default_profile_normal chuckwebster Moderator: Dr G is Davies award winner and his winning application is on HIMSS website (and my blog!)
11:36 AM Apr 5th from txt
default_profile_normal chuckwebster Talk ends: 10 people crowd around DR G (ROI, lifestyle, and pat satisfaction)
11:40 AM Apr 5th from txt
default_profile_normal chuckwebster Is it certified? Yes
11:40 AM Apr 5th from txt
default_profile_normal chuckwebster Wow! That was intense trying to twitter an entire hour long talk. 40 tweets. I’ll see if I can get Dr G’s powerpoint and post it.
12:10 PM Apr 5th from txt
default_profile_normal chuckwebster Attending EHR For The Medical Practice (Kimker) presentation. MASSPRO (seen some wonderful forms for collecting workflow data from them)
12:13 PM Apr 5th from txt
default_profile_normal chuckwebster Big compliment to Dr G’s previous presentation on workflow (this pres is more about analyzing workflow)
12:17 PM Apr 5th from txt
default_profile_normal chuckwebster Redesign workflow to accommadate ehr vs beneft from ehr
12:14 PM Apr 5th from txt
default_profile_normal chuckwebster Been reflecting on Dr G’s questions, at least 6-7 actually used to phrase “workflow management system” including several solo practitioners
12:25 PM Apr 5th from txt
default_profile_normal chuckwebster Speaker said that Dr G’s ehr has specific workflows for specific tasks, but most EHRs cnnt do tht, so may have to use customized templates
12:28 PM Apr 5th from txt
default_profile_normal chuckwebster That’s it for ed sessions today. Nw to find a coffee house, get online, and do some work. Thnks fr following my twitter updates this morning
12:58 PM Apr 5th from txt
default_profile_normal chuckwebster Audience member caught up with me, is your system enterprise ready, what do you mean? Handle multiple specialty workflows, absolutely!
1:31 PM Apr 5th from txt

Currently Attending The 2009 HIMSS Conference In Chicago

Short Link: http://j.mp/8uPelK

I will be, or am, or was (depending on when you read this) at the 2009 HIMSS conference in Chicago from Saturday April 4th to Tuesday April 8th.

Dr. Gonzalzles’ presentation ”Workflow Management EMR Systems and the Primary Care Physician,” is on Sunday, April 5, at 9:45 AM – 10:45 AM in Room S403b at the McCormick Place Convention Center. If you attend I hope you will introduce yourself. Or email me at webster at encounterpro dot com (which I frequently check on my cell phone) if you’d like to get together to talk about EHRs, workflow management systems, or business process management. (Perhaps I should look into Twitter for this sort of thing.)

P.S. I actually feel a little guilty that this post is so short. While I originally intended to post only intermittently, I have in fact posted once a week for two months. This might be becoming a habit. In fact, I’m beginning to look forward to each post a bit like a columnist (“Another deadline! What will I write about?”) but also a bit like a novelist dealing with unruly characters (“What’s going to happen next?”).

What’s So Special about EHR Workflow Management Systems?

Short Link: http://j.mp/4Io0Ya

Someone contacted me with a challenge, “What’s so special about EHR workflow management systems and why can’t it be added to an existing EHR?”

Here is my answer:

Many EHRs are cumbersome, inflexible, and difficult to optimize with respect to their process workflow. Implemented correctly, an EHR workflow management system is graceful, flexible, and optimizable. If you understand the reasons for these advantages you will also understand why other kinds of EHRs cannot easily fix their problems. By the way, this is not to say that EHRs have not added important task management capabilities in recent years. However, this task management is typically based on “frozen” workflow.

soap_box_speaking

By “cumbersome” I mean that most EHRs require expensive human users to do what should be done by less expensive combinations of software and hardware. Physicians don’t want to become data entry clerks; they just want to click once and as Star Trek’s Captain Picard says, “Make it so!”

By “inflexible” I mean there is no way for the user to easily improve task workflow in order to spend more time on value-added tasks directly benefiting patient and user. If an application requires a physician to click five times, four clicks of which are effortful and extraneous, there needs to be some sort of workflow or process editor to eliminate the four non-value added clicks that are wasting the physician’s time.

By “difficult to optimize with respect to process workflow”, I mean there is no way to systematically guide changes in EHR workflow so as to maximize patient satisfaction, clinical outcomes, and practice profitability goals. In contrast, processes driven by EHR workflow management systems can be analyzed through use of business process management (BPM) tools that suggestions ways to improve workflow processes. Workflow engines create workflow logs. These are step-by-step records of who clicked on what, when, where, and why. BPM tools can analyze these logs (through a technique called workflow or process mining) and suggest better workflows that will minimize non-value added tasks. This in turn frees human resources to be reallocated to value-added tasks that contribute to happier, healthier patients and greater take home income.

OK, fair enough, EHRs will need to incorporate WfMS technology. Why can’t EHR vendors just add workflow engines, process definitions, workflow logs, and process mining to existing EHRs? The word “workflow” has certainly been an EHR industry buzzword for the last five years. However, in the marketing din “workflow” has become almost meaningless. Yes, addition of messaging facilitates person-to-person coordination; interfaces make application-to-application coordination possible; and patient tracking is about coordinating the most important resource of all, patients. While these added capabilities can improve workflow, they aren’t workflow management. A workflow management system by definition requires a workflow engine that consults workflow or process definitions to drive tasks to people and applications. Tacking on messaging, interfaces, and tracking is a lot easier than picking up an EHR that does not rest on a workflow management system and then inserting beneath it a fully fledged workflow management system foundation, with its powerfully directive workflow engine, powerfully customizable process definitions, and powerfully analyzable workflow log.

Here is one way to think about “adding” a workflow management system to an existing EHR. When you look at a non-WfMS-based EHR you are looking at screens that are the result of a human programmer creating areas that will contain buttons and menus and so on, then placing these buttons and menus in these areas, and then connecting those buttons up with various functions and procedures that have also been created by a human programmer. This is why we need programmers in the first place; if it could be done more easily or less expensively we’d do it that way instead.

This is in fact what a workflow management system allows a non-programmer to do, to directly edit application workflow. Who creates the areas for the buttons, and then the buttons, and then connects the buttons with what happens when the buttons are pressed? The workflow management system does. You should now see why a workflow management system cannot simply be added to an existing computer application. The existing application was created by a human programmer. In order to add a workflow management system foundation you will have to replace the programmer with a workflow management system to regenerate the application. Therefore existing systems will need to be rewritten (by the very definition of how workflow management systems operate).

Several years ago we were giving a demo to a visiting physician who had happened to have taken some programming courses in college. During the demo the physician said, wait a minute, I thought you were going to demonstrate integration with my favorite patient questionnaire application. To which the user said, “Oops!” And then proceeded to pop up the process workflow definition editor within which he added the questionnaire task, set a couple of properties of that task, dismissed the editor, and then gave the demo again. This time the questionnaire screen popped up automatically at the intended step in the workflow. To which the visiting physician said, “I get it!” An EHR workflow management system is a development environment that lets non-programmers to create and edit their own EHR workflow systems. Exactly.

Adding a workflow management system to an existing EHR application would be like adding a foundation to a standing skyscraper or a hull to a floating ship. Many current EHRs will have to be rebuilt on top of workflow management systems foundations if they are to become the graceful, flexible and optimizable EHR systems that healthcare needs in the long run.

I have (somewhere) a copy of a several hundred page user manual for a typical document management system-oriented EHR. It has a hundred pages of chapters about workflow. These chapters tell an human user what to click, in what order, and in what circumstances in order to perform a variety of tasks. If you look at chapters about workflow for an EHR workflow management system, you will see that they are about editing EHR workflows so that these tasks happen automatically after a user just clicks the button and “fires and forgets.”

EHR workflow management systems are built on a foundation that can “Make it so!” This is the EHR workflow management system unique selling proposition *and* its barrier to entry for EHRs that are not workflow management systems.

Survey: EHR Workflow Management System Features & Functions

Short Link: http://j.mp/86lspq

In 2003 and through 2005, I contributed to, and updated, the General Workflow Management Criteria portion of the “Workflow Management Survey: Ambulatory EHR Systems” survey, conducted by Andrew & Associates, which appeared in Advance for Health Information Executives. It’s been four years WfMS technology has been creeping into the EHR mainstream, so it’s worth an update and a raising of the bar, so to speak. 

Here are the originally described EHR WfMS features and functions:

  1. System displays selected worklists for active cases.
  2. System permits employees to view and complete work items that have been assigned to other employees.
  3. System creates reminders for work items that have not been completed when due.
  4. Users can selectively modify assigned work items.
  5. System maintains a record of various changes made to work items.
  6. System maintains various records of completed activities.
  7. Users can selectively correct or modify records of completed activities.
  8. System has a workflow engine that automatically creates work items based on a workflow definition using various defined criteria.
  9. Users can customize workflow definitions to match their internal processes using various defined criteria.
  10. Users can define roles and resources that will receive task assignments.
  11. Users can edit workflow definitions using a graphical user interface.
  12. Software vendor provides workflow definitions for individual medical specialties.

A good start six years ago, however they actually barely scratch the descriptive surface of a fully functional EHR WfMS. (Although, if one had to prioritize, criteria 8, 9, and 11 are arguably the most important and the basis for my Litmus Test for Detecting Frozen EHR Workflow post.)

table_ehr_wfms_ff

I’ve tentatively expanded these 12 criteria almost fourfold on a special page I’ve added to this blog titled, Electronic Health Records Workflow Management Systems Features & Functions Survey. If you fill out the survey, whatever comes in over the transom I’ll summarize back to the blog. By “tentatively” I mean that this survey is more of a rough public draft intended to attract comment, critique, and suggestions for improvement than anything that could be considered a polished final product.  I’d rather put out something imperfect now so it can be improved by critique than hold onto it while making successive smaller and smaller improvements.

This EHR WfMS F&F Survey is *not* intended to be an exercise in systematically comparing EHR WfM and EHR WfM-like systems. It could be used that way, however my primary goal is to raise awareness about the details and importance of EHR WfMS features/functions, and to create and improve a conceptual framework for understanding EHR WfMS and EHR WfMS-like applications.

You are welcome to submit data anonymously or not, to complete all or only some items, or to only provide comments on specific items. I am particularly interested in comments from workflow management systems and business process management professionals who would like to see this technology and way of thinking brought to healthcare in general and electronic health records in particular.

I’ll make minor revisions to the page in place. However, for larger revisions I’ll release a new version of the survey and archive the old one.

Yes, I know my terminology may be somewhat at variance with that of the WfMS industry. And yes, I know that in some cases I essentially ask the same question more than once in different ways. This is partly due to the old survey stratagem of asking the same question in different ways as a form of validity check and partly due to my observation that, in the electronic health records industry, workflow management systems terminology is not yet, in fact, typically standard with that of the workflow management systems industry. In other words, an EHR professional may use (and therefore recognize) other words than that adopted by the WfMS industry and I am trying to be accessible to both EHR and WfMS professionals.

I eventually plan to add business process management oriented material, however while WfMS ideas and terminology have become relatively standard, BPM is a moving target, so I’ll focus first, here, on WfMS aspects of EHR functionality. That said, implications of BPM for electronic health records are fascinating and important, so I’ll certainly post on the topic.

My hope is that improving these survey criteria might eventually become a community effort. Perhaps some sort of open source model based on ideas from the creative commons might apply. I’m thinking of a downloadable version coded in XML to facilitate sharing and co-development. (Is there an XML questionnaire schema that might be appropriate here?) I’m open to suggestions.

Football Plays and Clinical Workflow

Short Link: http://j.mp/8xfEPJ

A friend of mine is Dave Hubbard, the motivational speaker, an All-American collegiate athlete who played professional football in the 1970’s for Hank Stram of the New Orleans Saints and then the Denver Broncos. Dave is extremely familiar with healthcare both professionally (serial entrepreneur) and personally (broke his back jumping out of a perfectly good airplane!).

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We’ve had a series of interesting conversations about, of all things, football plays and EHR workflow. We co-wrote the following post to see if we might enlist you in telling us if you think we’re on to something, or not.

–Chuck & Dave

Medical offices are like football teams: an offensive line moves a patient encounter forward while a defensive line seeks to create chaos and stop encounter progress. This analogy is more productive than you might think!

Medical office staff members interact in ways that are similar to a football team. For example, they have an offensive line whose responsibility it is to efficiently, effectively, and flexibly move an encounter from waiting room to checkout. There’s a quarterback who calls plays. Sometimes it’s the physician who directs staff to administer a vaccination or auditory test; sometimes the plays are called automatically based on the reason for the patient’s visit, such as “well child” versus “ear ache.”

Tasks are “passed” among team members, such as a nurse gathering vitals and checking medications and allergies before passing the assessment and treatment tasks to the physician. “Dropping the ball” results in inefficiency that slows the encounter and ineffectiveness that affects patient care and physician revenue.

The defensive line may be less obvious, but it consists of threats to the accomplishment of efficient, effective, flexible workflow. It is the offensive line’s responsibility to protect this workflow. For example, the phone nurse blocks defensive line interruptions that would otherwise distract the physician from maximizing use of the most important and constrained resource in the practice, his or her time. Anyone (or anything) who contributes to the hassle factor of practicing medicine is part of the defensive line.

Similarities between a medical team and a football team are more than an amusing analogy. All teams are cognitive systems, and their study is called team cognition (with contributions from distributed cognition). Shared mental models, workspace awareness, radar views, and teams of experts versus expert teams are topics of team cognition that apply to all teams, including those in medicine and football.

Using this football metaphor (and some ideas from cognitive science), we encourage you to think (and comment!) about office processes from the perspective that to win, the ways in which the plays are being run must be examined. Doing so will allow people to express what they are most proud of, but also to critically evaluate performance problems in a constructive way, one in which everyone is committed to success.

Questions to consider:

How is your medical practice similar to a football team?

What position does each employee play? Who is offense? Who is defense? Are there any special teams?

Who is the quarterback? The coach? Does everyone know their position?

What about the referee? The coach? The patient? The fans?

Who owns the team? Is there an owners’ association? A players’ association?

If your medical practice were a football team, what would be your version of the following: Holding? Tripping? Unsportsmanlike conduct? Unnecessary roughness? Running versus passing? Huddling? Incomplete pass? Field goal versus touchdown? Memorizing key plays? Time-out? Substitutions?

Suppose you could review game films with your staff. What are examples of plays you’ve run to achieve major yardage or touchdowns?

What are examples of plays where you’ve thrown for a loss, fumbled the ball, or suffered interceptions? Why did they occur and what can you do to keep them from happening again? How do you define victory?

Do different styles of medical practice lend themselves to different sports analogies? Soccer? Golf? Which do you suggest and why?